Medicare Information

The Federal Government sets strict guidelines about the examinations that are performed by Hunter Imaging Group and which of these will attract a Medicare Rebate.

See below for criteria about specific examinations and the physicians that can refer for various medical imaging services.

If you have any more queries about the Medicare Benefits Schedule in relation to our examinations then please contact Doctor Direct on (02) 4925 5451 or any of the Client Services Team.

Greater Access for Patients to Medicare Eligible MRI.

In addition to the GP MRI Paediatric items announced in 2012, the Federal Government have extended MRI Medicare eligibility to General Practitioner referred patients who are 16 years or older.

Four new items have been added to theMedicare Benefits Schedule (MBS) for certain regions and clinical conditions. The table below summarises the four new items along with the paediatric items and the clinical conditions required by Medicare.

Table 1: The new General Practitioner Referred MRI Regions and associated clinical criteria

Patients 16 Years or Older

Region Criteria
Head
  • unexplained seizure(s)
  • unexplained chronic headache with suspected intracranial pathology
Cervical Spine 1
  • cervical radiculopathy
Cervical Spine 2
  • cervical spine trauma
Knee
  • inability to extend the knee suggesting the possibility of acute meniscal tear; or
  • clinical findings suggesting acute anterior cruciate ligament tear.

Patients <16 years

Region Criteria
Head
  • unexplained seizure(s)
  • unexplained headache where significant pathology is suspected
  • paranasal sinus pathology which has not responded to conservative therapy
Spine Following radiographic examination for any of the following:
  • significant trauma
  • unexplained neck or back pain with associated neurological signs
  • unexplained back pain where significant pathology is suspected
Knee Following radiographic examination for internal joint derangement.
Hip Following radiographic examination of any of the following:
  • suspected septic arthritis
  • suspected slipped capital femoral epiphysis
  • suspected Perthes disease
Elbow Following radiographic examination where a significant fracture or avulsion injury is suspected that will change management.
Wrist Following radiographic examination where scaphoid fracture is suspected.

To view our MRI locations, simply click on either Charlestown, Cardiff or East Maitland.

If you any any questions with regard to these changes, please feel free to speak to one of our specialised MRI Radiologists by phoning Doctor Direct on 4925 5451. Alternatively, send an email to hig.DoctorDirect@sonichealthcare.com.au.

All examinations performed by Hunter Imaging Group are done so under the Medicare Benefits Schedule (MBS). For a patient to be eligible for a Medicare rebate there are certain criteria that all referrals must display.

  • Referrer name
  • Referrer provider number
  • Referrer contact details
  • Examination requested
  • All relevant clinical history

Hunter Imaging Group provides personalised stationary free of charge to assist our referrers in correctly filling out a referral. If you are interested in receiving personalised request forms please contact our Doctor Direct line.

Hunter Imaging Group charges a different Medicare Item Number for BMD examinations depending on the patient’s clinical history. If the patient does not fit into one of these criteria set by the Medicare Benefits Schedule (MBS) the patient will be charged a private fee and no Medicare rebate will apply.

In addition to the information below Hunter Imaging Group provides specialised tick-box style request pads to our referring physicians. These can be ordered free of charge by calling our Doctor Direct line.

Item number Criteria
   
12306 Performed when:
  • 1 or more fractures have occurred after minimal trauma (this can only be used once for each fracture); or
  • Monitoring of osteoporosis proven by previous bone densitometry;
  • Scan at least two years prior with a Z score of -1.50 or lower, or T score of -2.50 or lower.
12312 Performed when:
  • Prolonged & current glucocorticoid therapy (as per dose limits outlined in MBS)
  • Conditions associated with excess glucocorticoid secretion;
  • Male hypogonadism; or
  • Female hypogonadism lasting more that 6 months before age 45
12315 Performed when:
  • Primary hyperparathyroidism
  • Chronic liver disease;
  • Chronic renal disease;
  • Proven malabsoptive disorders (eg. Coeliac or Chron’s Disease)
  • Rheumatoid arthritis; or
  • Conditions associated with thyroxine excess
12321 Performed when:
  • If performed 12 months following a significant change in therapy

Hunter Imaging Group performs Nuchal Translucency scans in line with the Medicare Benefits Schedule (MBS). For a patient to be eligible for a Medicare rebate they must fit one of the following criteria and the applicable condition must be present and stated on the request form.

  1. The patient is 12-16 weeks of gestation and referred by a medical practitioner, and
  2. One or more of the following conditions are present:
  • Hyperemesis
  • Risk of foetal abnormality
  • Previous post dates delivery
  • Abdominal wall scarring
  • Inflammatory bowel disease
  • Advanced maternal age
  • Toxaemia of pregnancy
  • Significant maternal obesity
  • Previous caesarean section
  • Suspicion of ectopic pregnancy
  • Diminished symptoms of pregnancy
  • Previous pelvis or spinal trauma or disease
  • Pregnancy after assisted reproduction
  • Suspected or known uterine disease
  • Suspected or known cervical incompetence
  • Diabetes mellitus
  • Hypertension
  • Autoimmune disease
  • Alloimmunisation
  • Maternal infection
  • Bowel stoma
  • Drug dependency
  • Thrombophilla
  • Abdominal pain or mass
  • Liver or renal disease
  • Poor obstetric history
  • Risk of miscarriage
  • High risk pregnancy
  • Uncertain dates
  • Cardiac disease

Hunter Imaging Group operates three Medicare Eligible MRI scanners located at Cardiff, East Maitland and Tamworth.

At all three of these locations patients who present for a MRI are scanned in accordance with the Medicare Benefits Schedule (MBS). This means for a patient to be entitled to a Medicare Rebate their request must be from a Specialist Physician and comply with specific indications which must be present and stated on the request form.

Below are a list of the indications for the scans performed by Hunter Imaging Group:

Anatomical Region Indication
Breast Magnetic Resonance Imaging performed under the professional supervision of an eligible provider at an eligible location where the patient is referred by a specialist or by a consultant physician and where;
  1. A dedicated breast coil is used; and
  2. The request for scan identifies that the woman is asymptomatic and is less than 50 years of age; and
  3. The request for scan identifies either;
  • That the patient is at high risk of developing breast cancer, due to 1 of the following:
  • that generic testing has identified the presence of a high risk breast cancer gene mutation.
  • 3 or more first or second degree relatives on the same side of the family diagnosed with breast or ovarian cancer;
  • 2 or more first or second degree relatives on the same side of the family diagnosed with breast or ovarian cancer, if any of the following applies to at least 1 of the relatives:
  1. Has been diagnosed with bilateral breast cancer;
  2. Had onset of breast cancer before the age of 40 years;
  3. Had onset of ovarian cancer before the age of 50 years;
  4. Has been diagnosed with breast and ovarian cancer, at the same time or at different times;
  5. Has Ashkenazi Jewish ancestry;
  6. Is a male relative who has been diagnosed with breast cancer;
  • 1 first or second degree relative diagnosed with breast cancer at age 45 years or younger, plus another first or second degree relative on the same side of the family with bone or soft tissue sarcoma at age 45 years or younger; or

Scan of both breasts for:

  • detection of cancer (R)

 
Head Unlimited referrals:
  • Tumour of the brain or meningies
  • Inflammation of the brain or meningies
  • Skull base or orbital tumour
  • Stereotactic scan of brain

Benefits payable for each service on 3 occasions in 12 months:

  • Acoustic neuroma
  • Pituitary tumour
  • Toxic or metabolistic or ischemic encephalopathy
  • Demyelinating disease of the brain
  • Congenital malformation of the brain or meningies
  • Venous sinus thrombosis
  • Head trauma
  • Epilepsy
  • Stroke
  • Carotid or vertebral artery dissection
  • Intracranial aneurysm
  • Intracranial arteriovenous malformation
Head and neck vessels Benefits payable for each service on 3 occasions in 12 months:
  • MRI/MRA of extra/or intracranial circulation for stroke

 
Head and cervical spine Unlimited referrals:
  • Tumour of the CNS of meningies
  • Inflammation of the CNS or meningies

Benefits payable for each service on 3 occasions in 12 months:

  • Demyelinating disease of the CNS
  • Congenital malformation of the CNS and meningies
  • Syrinx (congenital or acquired)
Spine – one region or two contiguous regions Unlimited Referrals:
  • Infection
  • Tumour

Benefits payable for each service on 3 occasions in 12 months:

  • Demyelinating disease
  • Congenital malformation of the spinal cord or the corda equina or meningies
  • Myelopathy
  • Syrinx (congenital or acquired)
  • Cervical radiculopathy
  • Sciatica
  • Spinal canal stenosis
  • Previous spinal injury
  • Trauma
Spine – three contiguous regions or two non-contiguous regions Unlimited Referrals:
  • Infection
  • Tumour

Benefits payable for each service on 3 occasions in 12 months:

  • Demyelinating disease
  • Congenital malformation of the spinal cord or the corda equina or meningies
  • Myelopathy
  • Syrinx (congenital or acquired)
  • Cervical radiculopathy
  • Sciatica
  • Spinal canal stenosis
  • Previous spinal injury
  • Trauma
Cervical spine and brachial plexus Benefits payable for each service on 3 occasions in 12 months:
  • Tumour
  • Trauma
  • Cervical radiculopathy
  • Previous surgery
Musculoskeletal system Unlimited referrals:
  • Tumour arising in bone or musculoskeletal system, this excludes tumours arising in breast, prostate or rectum
  • Infection arising in bone or musculoskeletal system, this excludes tumours arising from the breast, prostate or rectum
  • Ostenocrosis

Benefits payable for each service on 3 occasions in 12 months:

  • Derangement of hip or its supporting structures
  • Derangement of shoulder
  • Derangement of knee
  • Derangement of ankle and/or foot
  • Derangement of one or both TMJ’s
  • Derangement of hand and/or wrist
  • Derangement of elbow

Benefits payable for each service on 2 occasions in 12 month:

  • Gaucher disease
Cardiovascular system Benefits payable for each service on 2 occasions in 12 months:
  • Congenital disease of the heart or a great vessel
  • Tumour of the heart or a great vessel
  • Abnormality of the thoracic area

Benefits payable for each service on 3 occasions in 12 months:

  • MRA for vascular abnormality in a patient with a previous anaphylactic reaction to iodinated contrast medium
  • MRA for obstruction of the superior vena cava, inferior vena cava or a major pelvic vein
Body Benefits payable for each service on 1 occasion within 12 months:
  • Adrenal mass in a patient with a malignancy which is otherwise resectable
Pelvis and upper abdomen Benefits payable on 1 occasion only:
  • Pelvis for the staging of histologically diagnosed cervical cancer at FIGO stages 1B or greater
  • Pelvis and upper abdomen, in single examination for the staging of histologically diagnosed cervical cancer at FIGO stages 1B or greater
  • Magnetic resonance cholangiopancreatography (MRCP) for suspected billary or pancreatic pathology
Persons under the age of 16 Benefits payable for each service on 1 occasion in 12 months:
  • MRA for vasculature of limbs prior to limb or digit transfer surgery in congenital limb deficiency syndrome

Benefits payable for each service on 2 occasions in 12 months:

  • Post-inflammatory or post-traumatic physeal fusion
  • Gaucher disease

Unlimited referrals:

  • Pelvic or abdominal mass
  • Mediastinal mass
  • Congenital uterine or anrectal abnormality

 

Hunter Imaging Group scans patients that require shoulder and knee ultrasounds in accordance with the Medicare Benefits Schedule (MBS). In May 2003 the Health Insurance Commission issued amendments to the benefits payable for ultrasound of the shoulder and knee.

The amendments outline that Medicare will only rebate these examinations when the request form specifically includes one of the following suspected pathologies…

Shoulder Ultrasound

 

 

 Benefits are payable when referred with suspicion of the following clinical conditions:

  • Evaluation of injury to tendon, muscle or tendon/muscle junctions including tears, calcification or tendinosis
  • Rotator cuff tear/calcification/tendinosis of biceps, subscapular, supraspinatus or infraspinatus
  • Biceps subluxation
  • Capsulitis and Bursitis
  • Evaluation of mass, including ganglion
  • Occult fracture
  • Acromioclavicular joint pathology

Benefits are not payable when referred for non-specific shoulder pain alone.
Knee Ultrasound Benefits are payable when referred with suspicion of the following clinical conditions:

  • Abnormality of tendons or bursa about the knee
  • Meniscal cyst, popliteal fossa cyst, mass or pseudomass
  • Nerve entrapment, nerve or nerve sheath tumour

Benefits are not payable when referred for non-specific knee pain alone or other known conditions including:

  • Meniscal and cruciate ligament tears
  • Assessment of chondral surfaces

At Hunter Imaging Group we bill patients referred by Allied Health practitioners (Physiotherapists, Chiropractors, Osteopaths and Podiatrists) according to the Medicare Benefits Schedule (MBS).

The MBS states that these referrers’ patients are only entitled to a rebate when referred for the following selected examinations. If a patient presents with a referral for an examination that is not in the list below then they will be charged the private fee.

Physiotherapists, Chiropractors, Osteopaths

  • X-ray hip
  • X-ray Pelvis
  • X-ray cervical spine
  • X-ray thoracic spine
  • X-ray lumbar spine
  • X-ray sacrococcygeal spine
  • Long spinal image or multiple spinal regions

Podiatrists

  • Ultrasound ankle or hind foot
  • Ultrasound mid or fore foot
  • Ultrasound lump
  • X-ray foot
  • X-ray leg
  • X-ray knee
  • X-ray femur
  • Long leg image for leg alignment or leg lengths

Nurse Practitioners

  • Ultrasound Shoulder or Upper Arm (only available if suspected injury to tendon, muscle or muscle/tendon junction, rotator cuff tear, sublaxation of biceps, mass, occult fracture, or AC joint pathology)
  • Interventional Musculoskeletal Ultrasound (only available when request states that US-guided intervention be performed only if clinically indicated)
  • Ultrasound breast
  • Ultrasound Chest or Abdominal Wall
  • Ultrasound Forearm or Elbow
  • Ultrasound Abdomen
  • Ultrasound hip*, groin, buttock or thigh (*US exams for the evaluation of hip dysplaysia, spine and spinal cord are also available in paediatrics)
  • Ultrasound Hand or Wrist
  • Ultrasound Prostate (Prostate US only available if seen and recommended by a Urologist or Oncologist in the last 60 days)
  • Ultrasound Knee (Knee US not available for non-specific conditions. Only in suspected issues with tendons or bursae, mass or cyst, nerve or collateral ligaments)
  • Ultrasound Skin and Subcutaneous Structures
  • Ultrasound Lower leg, ankle and foot
  • X-ray Thoracic Inlet or Trachea
  • X-ray Shoulder or scapula
  • X-ray Clavicle
  • X-ray Chest
  • X-ray Ribs and sternum
  • X-ray hand, wrist, forearm, elbow and/or humerus
  • X-ray Pelvic girdle
  • X-ray Hip joint
  • X-ray femur, internal fixation or trochanteric fracture
  • X-ray foot, ankle, leg ,knee and/or femur